Professor Khaled Meflah discusses the principal clinical activities and innovations in the field of radiotherapy at the François Baclesse Cancer Center in Caen, France
Khaled Meflah PhD
Centre François Baclesse,
The therapeutic provision of cancer care in Basse-Normandie (Lower Normandy) is both dispersed, in a region maintaining a strong rural identity, and centralised around a single point of reference: the Caen hospital platform. comprising the Centre Hospitalier Universitaire (CHU; University Teaching Hospital) and the Centre de Lutte Contre le Cancer (Regional Cancer Center) François Baclesse.
The Centre François Baclesse is a regional cancer center (RCC). It is an institution, that is, a private organisation that participates in the public hospital service.
It is a member of the UNICANCER group, which unites 18 RCCs. UNICANCER is a hospital group dedicated exclusively to the fight against cancer.
The Centre François Baclesse treats more than 6500 new patients annually, at all stages of disease. This activity is strongly rooted in the network of cancer care. Depending on the tumour location, this treatment involves 30% to 80% of all adult malignancies detected in the region.
Like all the RCCs, the Centre François Baclesse has a threefold mission in oncology:
Founded in 1923, the Centre has been located in the hospital area north of the city of Caen since 1973, close to its principal local partners: the Centre Hospitalier Régional Universitaire (CHU), the Faculties of Medicine and Pharmacy, the School of Paramedicine, the Grand Accélérateur National d’Ions Lourds (GANIL; National Large Heavy Ion Accelerator), the medical cyclotron (CYCERON), and the University.
The Centre François Baclesse has 875 employees, including 98 physicians and scientific personnel (that is, 800 full-time equivalents (FTEs), of which there are 83 FTE physicians and scientific personnel). Its annual operating budget is €83 million, and its investment capacity is €2.8 million. Since 2005, date of entry into force of the budgetary reform ‘Tarification à l’activité’ (activity-based payment model), the Centre’s revenue is derived mainly from its hospital billing services. Because of its status, it is also entitled to receive donations and bequests (art. L6162 -2 of the Public Health Code).
The Centre offers alternatives to full hospitalisation, such as day care and outpatient surgery. It also offers rapid treatment regimes for breast and thyroid disease.
Clinical activities and radiotherapy
With over 56,000 visits per year and almost 25,500 hospitalisations, the Centre François Baclesse is the principal cancer-focused location in the Normandy region. Each year, approximately 3350 patients undergo surgery, 2600 patients are treated with radiotherapy (approximately 48,450 radiotherapy sessions) and 13,800 chemotherapy sessions are delivered. The external activity is very significant, particularly for breast care (nearly 6700 consultations), and imaging activities (19,100 computed tomography (CT) scans for 7300 passages, 4500 magnetic resonance imaging (MRI) scans and 6200 nuclear medicine examinations).
This oncology activity involves the totality of cancer disease in adults, with particular emphases on diagnostic breast examinations and breast cancer (about 1000 new breast cancers per year), bronchopulmonary and prostate cancer (more than 300 patients each year).
The radiotherapeutic technical capability of the RCC is in a position almost unique in France for conducting comparative evaluations of the CyberKnife® and TomoTherapy® systems, depending on the type of pathology (Box 1).
The radiotherapy service of the RCC is the clinical and medical physics referent for the ARCHADE project, aimed at creating a European centre for research and development in cancer and Hadron therapy, a promising innovation in radiotherapy, in Caen in 2016.
Implementing innovative techniques
The distribution of patients reflects the statistics reported at a national level, with a predominance of breast tumours in women – 25% of recruitment for the department – and urological (mostly prostate) cancers in men – 13% of recruitment. The remaining patients mostly have digestive tumours (the high rate of oesophageal tumours observed over a long time is, however, decreasing markedly) and lung cancers. Finally, for many of our patients – about one third – there is palliative radiation, the goal of which is, above all, improvement of symptoms and patient comfort.
The Centre François Baclesse holds the operating license for the radiotherapy site of the Centre Hospitalier Public du Cotentin (Cotentin Public Hospital), located in Cherbourg.
There is a Day Hospital of 40 places, capable of receiving up to 80 visits daily for ambulatory chemotherapy treatments. This department can also carry out novel medical therapeutic approaches (for example, targeted therapy, monoclonal antibodies).
Cancer care options
The activities in this area are: gynaecologic cancers; breast cancer surgery including reconstruction; digestive cancers; head and neck cancers and reconstruction; thyroid surgery, where the Centre plays a major role in the region; sarcomas of soft tissue; and skin cancers.
Its points of excellence are:
- A top-flight radiotherapy service (TomoTherapy®, CyberKnife®)
- A performing clinical biology and oncology laboratory (next generation sequencing)
- Accredited by the INCa (National Cancer Institute) as a centre for clinical trials, specialised in early-stage trials of innovative drugs in oncology
Establishment accredited V2012 by the Haute Autorité de Santé (National Authority for Health).
The radiotherapy staff is a team of 75.61 FTE professionals serving patients and comprising:
– 15 radiation oncologists
– 37.7 technicians
– 6.68 medical physicists
– Eight physical measurement technicians
– 4.40 reception/secretarial personnel
– 1.83 nursing assistants
– One medical physics supervisor
– One health supervisor
An exceptional treatment platform
Our group is part of the ‘happy few’ in France that deals with two of the the most sophisticated approaches in radiotherapy: TomoTherapy® and CyberKnife®. These technologies are derived from the revolutionary concept of intensity modulation of the beam (IMRT), developed through the past two decades, and under development in the major institutions. This approach exploits subtle alterations of the beam-fluency to maximise ‘dose-shaping’ to the tumour and dose-sparing of close normal structures. It is predicted that this approach will expand in the upcoming years, to cover at least half curative treatments, not to mention the benefit to advanced presentations.
TomoTherapy® and CyberKnife® are very powerful technologies that the radiation oncologist can exploit in complex but still common situations, such as escalating dose to ‘radio-resistant’ tumour processes, or limiting toxicity in sensitive patients (children, debilitated adults), or both. The two have in common a millimetre accuracy of the dose delivery. But their indications are complementary. The former (TomoTherapy®) combines an embarked CT scan for on-line daily verification of the patients’ position, and a rotational delivery of the therapeutical beam that covers complex and extended targets (up to 160cm), in a quick delivery mode.
We estimate that many complex beams’ arrangements can benefit from this technology, such as head and neck cancers close to spinal cord or salivary glands, cranio-spinal irradiation (used in adult and paediatric brain tumours), multiple primaries at presentation (for example, concomitant ENT, lung and esophageal cancers, multiple meningiomatosis), re-irradiation following failure to a previous treatment. These tumour sites are in a developmental phase at our institute, and other indications, such as total bony irradiation before bone marrow transplant, under discussion. The latter (CyberKnife®) has proven a unique tool to manage small (that is, <6cm or so) mobile targets, namely those located in the thorax and the upper abdomen.
Tracking is based on internal ± external fiducials. Its indications concern mainly patients with one or few metastases such as those located in the lungs, and liver, treated ‘semi-curatively’. Small mets abutting previously treated areas in the spine and brain are also good indications to minimise further devastating complications, such as myelopathy. A restricted number of fractions can be administered safely and improves greatly patient’s compliance and quality of life. We estimate that the early screening developed in prostate, breast, digestive, etc should considerably expand these indications in the future.
Hadron therapy, as mentioned above, is also an exciting avenue that we are contemplating in a further step, which is based on new types of radiation: the heavy charged particles (protons and carbon ions).
The TomoTherapy® and CyberKnife® were recognised in France by the Haute Autorité de Santé (HAS) in 2006, with validated indications, and relevant others still being researched. They are reimbursed since 2010, and enjoy increased rates for dedicated machines in the public sector only.
The technical platform comprises a site with four linear accelerators, containing high-performance equipment, such as multi-leaf collimation, and for some of them, the ability to modulate beam intensity during irradiation, to control it by on-board imaging, or to partially correlate the beam with the respiratory movements.
Treatment is safe. The preparation steps, which are fully computerised, are based on the use of CT imaging, often coupled with complementary MRI-type imaging and three-dimensional dose planning, and the treatment phase, is carried out under the permanent supervision of a radiation therapist specialist, assisted by a radiation physicist. The radiation therapy team consists of 15 senior physicians, seven physicists and approximately 30 radiotherapy technicians.
The RCC, through its development policy, will renovate two accelerators from its machines in the next two years, in order to continue improving the quality of care for patients.
The service currently utilises:
- One CyberKnife® system
- One TomoTherapy® system
- Four accelerators, including three with multi-leaf collimators
- Two tracking scanners, including one with a large tunnel
- One contact-therapy device
- One unit specifically for brachytherapy
– Five protected hospitalisation rooms
– Radiation (high rate, pulsed rate, low dose rate, permanent prostate implants of iodine-125 seeds)
Over the next few years, it is planned to orient research towards the use of radiation that is very different from current X-rays – or photons, that is protons or carbon ions (ARCHADE project).
From 2008 to the present day
When I took office in 2008, the Centre François Baclesse had a deficit corresponding to 5% of its annual gross revenue, placing it in the group of health facilities at financial risk. At the end of 2011, it achieved financial equilibrium, with a slight surplus. Box 2 summarises the data.
The institutional plan
The main measures that were implemented to ensure a return to balance in 2012 were:
– Organisational analysis and alignment of staff with the activity of the institution
– Redefinition of the mission of the Centre in line with cancer plans
– Strengthening the position of the referral institution, with a strong emphasis in particular on innovation in the treatment of patients
– Connecting with regional institutions to ensure complementarity in the provision of care.
The key success factors and obstacles
The major factor for success was the adherence of all Centre staff to the defined strategy whereas the main obstacle to implementation of this project was the relatively reduced ability to finance from investments.
Financing the equipment
The Centre’s financial situation does not generate a cashflow capable of self-financing these acquisitions. We have solicited the authorities, charitable organisations, the regional council, the general councils and donations for contributions, which we have supplemented by borrowing.
Working with the authorities
Domestic economic conditions reduced the operating margin of the ARS (Regional Health Agency), which could only make a modest contribution in terms of the necessary investments.
The discussion points that we highlighted were based on the need to ensure the provision of quality healthcare that is consistent with advances in science, and to promote clinical research.
The role of the Director
The main difficulty faced by a Director of a Centre in deficit is related to recognition of the credibility of his strategy. The development of an ambitious medico-scientific project that takes into account the requirements of the quality and the safety of treatment is a major element.
How is this project part of the Cancer Plan II?
The Centre’s medical project is based on the implementation of cancer plan measures: to adapt treatments in a manner consistent with evolving knowledge and practices; to promote access to innovative therapies; and to increase patient enrollment in clinical research protocols.
The place of radiotherapy
The special regional position of the Centre in the field of radiation required upgrading the technical platform, providing practitioners with high-performance equipment able to respond to the requirements necessary for treatment adaptations.
The contributions of the CyberKnife® and TomoTherapy® systems
The TomoTherapy® and CyberKnife® expand the cancer care offered in radiotherapy. They allow for more research, and place the radiotherapy service in a favourable position for innovation. In addition, the service is a central element of the ARCHADE project undertaken by the Basse-Normandie region, which concerns the development of Hadron therapy. Having a radiotherapy service with innovative equipment enhances the credibility of this innovative project.
There has been a wider recruitment for the indications impacted by the investments that have been made and it is undeniable that these investments have benefited patients in the surrounding regions. This situation can now promote new collaborations and sharing of skills that ensure greater inter-regional coherence.
Box 1: Radiotherapy activity data 2011
- 48,450 radiotherapy fractions (outpatient and hospitalisation activity)
- 3050 fractions with TomoTherapy® (start-up in March 2011, with gradually increasing activity)
- 421 CyberKnife® fractions (from January to end of October 2012. Start-up in January 2012)
- 2600 patients treated with radiotherapy
- 76 professionals serving patients
- 22,500 quality controls
Box 2: Financial data summary
2008: €75 million
2011: €83 million
Number of new patients treated per
year for all pathologies for the whole centre:
2008: 662 FTE
2011: 800 FTE